Federal Ministry of Health Health Sector Strategic Plan (HSDP-III) 2005/6-2009/10 Planning and Programming Department, 2005
Table of Contents Acronyms..v Preamble..ix 1. COUNTRY PROFILE... 1 1.1 INTRODUCTION... 1 1.2 GEOGRAPHY AND CLIMATE... 1 1.3 POPULATION... 1 1.4 EDUCATION... 2 1.5 ADMINISTRATIVE STRUCTURE... 2 1.6 THE SOCIO-ECONOMIC ENVIRONMENT... 3 1.7 HEALTH STATUS... 4 1.8 HEALTH SYSTEM ORGANIZATION... 6 1.9 HEALTH CARE COVERAGE AND UTILIZATION... 7 1.10 HEALTH CARE FINANCING... 9 2. OVERVIEW OF THE IMPLEMENTATION OF HEALTH SECTOR DEVELOPMENT PROGRAM-I AND II... 10 2.1. HEALTH SERVICE DELIVERY AND QUALITY OF CARE... 10 2.1.1. The Health Service Extension Programme (HSEP)... 10 2.1.2. Family Health Service... 11 2.1.3. Prevention and Control of Diseases... 14 2.1.4. Medical Services... 19 2.1.5. Hygiene and Environmental Health... 20 2.2. HEALTH FACILITIES CONSTRUCTION AND REHABILITATION... 22 2.3. HUMAN RESOURCE DEVELOPMENT (HRD)... 22 2.4. PHARMACEUTICAL SERVICES... 24 2.5. INFORMATION, EDUCATION AND COMMUNICATION (IEC)... 26 2.6. HEALTH MANAGEMENT AND MANAGEMENT INFORMATION SYSTEM... 27 2.7. MONITORING AND EVALUATION (M&E)... 28 2.8. HEALTH CARE FINANCING... 29 2.9. CROSSCUTTING ISSUES... 30 2.10. FINANCIAL RESOURCE ALLOCATION AND UTILIZATION... 33 3. HEALTH SECTOR DEVELOPMENT PROGRAMME-III... 35 3.1. THE POLICY FRAMEWORK... 35 3.1.1. Introduction... 35 3.1.2. National Policy Context... 35 3.1.3. The Global Health Policy Context... 45 3.2. VISION OF HSDP... 47 3.3. MISSION OF HSDP... 47 3.4. VALUES OF HSDP... 47 3.5. MANDATE ANALYSIS... 47 3.5.1. Mandates of the Federal Ministry of Health... 48 3.5.2. Mandates of the Regional Health Bureaus... 48 HSDP-III ii
3.5.3. Mandates that need to be verified and supported by Proclamation... 49 3.6. ANALYSIS OF STAKEHOLDERS... 49 3.7. ANALYSIS OF COLLABORATORS... 53 3.8. SWOT ANALYSIS... 54 3.9. GOALS, OBJECTIVES, STRATEGIES AND KEY ACTIVITIES OF HSDP-III... 57 3.9.1. Goals of HSDP... 57 3.9.2. Major Objectives of HSDP... 57 10.1.1. Objectives, Strategies and Key Activities of HSDP-III... 57 10.1.2. Health Service Delivery and Quality of Care... 58 10.1.3. Access to Services: Health Facility Construction, Expansion and Transport... 67 10.1.4. Human Resource Development... 68 10.1.5. Pharmaceutical Service... 70 10.1.6. Information, Education and Communication (IEC)... 71 10.1.7. Health Management, Management Information Systems and Monitoring and Evaluation... 73 10.1.8. Health Care Financing... 77 10.1.9. Crosscutting Issues... 78 10.2. STRATEGIC ISSUES OF HSDP-III... 80 10.2.1. Shortage, High Turnover and Mismanagement of Human Resource... 80 10.2.2. Inefficient Civil Service System... 82 10.2.3. Weak Procurement and Management of Drugs, Medical Equipment and Supplies 83 10.2.4. Lack of Emphasis to Preventive and Promotive Health Interventions... 83 10.2.5. Inappropriate and Low Quality of IEC/BCC Services... 84 10.2.6. Ineffectiveness of HMIS in supporting planning, M&E and the decisionmaking process... 84 10.2.7. Harmonization and Alignment... 85 10.2.8. Inadequate Health Service Delivery to Pastoralists Population... 87 10.2.9. Poor Coordination of Activities and Management of NGOs and the Private for Profit Sector... 87 10.3. STRATEGIC ACTION PLAN... 88 10.4. PROGRAMME IMPLEMENTATION ARRANGEMENTS... 95 10.4.1. GOVERNANCE... 95 10.4.2. DECENTRALIZATION AND COMMUNITY PARTICIPATION... 96 10.4.3. FINANCIAL MANAGEMENT... 96 10.4.4. PROCUREMENT AND LOGISTICS MANAGEMENT... 98 10.4.5. MONITORING AND EVALUATION (M&E)... 99 4. HSDP-III COSTING, FINANCING AND PERFORMANCE PURCHASING STRATEGIES... 101 4.1. COST OF PROGRAMS AND SERVICE DELIVERY STRATEGIES... 101 4.1.1. METHODOLOGY... 101 4.1.2. REACHING THE HEALTH MDGS IN ETHIOPIA... 102 4.1.3. THREE COSTING SCENARIOS FOR HSDP-III... 107 4.2. FINANCING PLAN... 111 4.2.1. EVOLUTION OF PUBLIC AND PRIVATE HEALTH SPENDING OVER HSDP-II... 111 HSDP-III iii
4.2.2. POTENTIAL SOURCES TO FINANCE COST OF HSDP-III... 112 4.3. MDG PERFORMANCE PACKAGE FUND... 112 SUMMARY AND MAIN HIGHLIGHTS OF HSDP-III-------------------------------------117 List of Tables Table 1-1 Comparison of Ethiopian Demographic data with that of the World and Sub- Saharan African Countries in year 2003... 5 Table 1-2 Regional Distributions of Health Facilities and their ratio to Population, 2003/4... 7 Table 2-1-Summary of Targets and Achievements during HSDP-I and II in Maternal and Child Health Services... 11 Table 2-2 The increase in the production of selected categories of Health Human Resource in Ethiopia, during HSDP I and II as compared to the 1989 E.C.... 23 Table 2-3- The total number of available human resources for health and availability during the HSDP I and II as compared to 1989 E.C... 24 Table 2-4 Capital and Recurrent Health Budget Utilization Rate for the year 2002/03 and 2003/04 by Region... 33 Table 3-1 Analysis of Internal Stakeholders... 50 Table 3-2 Analysis of External Stakeholders... 51 Table 3-3 Analyses of Collaborators... 53 Table 3-4 Strategic Action Plan... 89 Table 4-1 Key interventions and identified bottlenecks... 102 Table 4-2 Access and Coverage Targets for 3 Scenarios... 108 Table 4-3 HSDP-III Incremental Cost Estimates Summary for the Three Scenarios... 109 Table 4-4 HSDP-III Total Cost Estimates Summary for the Three Scenarios... 109 Table 4-5 HSDP-III Incremental Cost Estimate by Components... 110 Table 4-6 HSDP-III Incremental Cost Estimates by Service Delivery levels... 110 Table 4-7: HSDP-III Incremental Cost Estimates by Expenditure Items... 110 Table 4-8 Ethiopia: National Health Accounts Data for 1999/2000... 111 Table 4-9 HSDP-III Projected Financing Plan... 112 References LIST OF ANNEXES Annex -1 SWOT Analysis of HSDP Annex-2 List of Indicators for Monitoring HSDP at National Level Annex-3 Detailed Programmatic Indicators and Targets of HSDP-III Annex-4 Annex 4: Cost Estimates of Scenario 2 and Scenario 3 Annex 5: Total HSDP-III Estimated Cost by Regions Annex-6 Making Direct Budget Support Work Better for Health Services Delivery and the MDGs Annex-7 Emergency Preparedness and Response in health sector-hsdp III HSDP-III iv
ACRONYMS ADLI Agricultural Development-Led Industrialization AIDS Acquired Immunodeficiency Syndrome ALERT All-African Leprosy Research and Training Center ANC Ante Natal Care ARI Acute Respiratory Infection ARM Annual Review Meeting ART Anti Retroviral Therapy ARV Anti-retroviral BCG Bacillus Caulmette Guerin BEOC Basic and Emergency Obstetric Care BOF Bureau of Finance BOFED Bureau of Finance and Economic Development CB Capacity Building CBOs Community-based Organizations CBRH Community-based Reproductive Health CDTI Community based Distribution and Treatment with Ivermectin CHAs Community Health Agents CHWs Community Health Workers CJSC Central Joint Steering Committee CMH Commission on Macroeconomics and Health CR Consolidated Report CRDA Christian Relief and Development Association CSA Central Statistical Authority CSR Country Status Report on Health & Poverty CSRP Civil Service Reform Program CSW Civil Service Workers DACA Drug Administration and Control Authority DAG Development Assistance Group D&C Dilation and Curettage DOTS Directly Observed Treatment Short Course DPPC Disaster Prevention and Preparedness Commission DPT Diphtheria, Pertussis and Tetanus Vaccine EC Ethiopian Calendar EDHS Ethiopian Demographic and Health Survey 2000 EHNRI Ethiopian Health and Nutrition Research Institute ENA Essential Nutrition Actions EFY Ethiopian Fiscal Year EHD Environmental Health Department EHSP Essential Health Service Package EHW Environmental Health Worker EOC Emergency Obstetric Care EPHA Ethiopian Public Health Association EPI Expanded Program of Immunization ESHE Essential Services for Health in Ethiopia EU European Union FBOs Faith Based Organizations FGOE Federal Government of Ethiopia FLHW Front Line Health Worker FMOE Federal Ministry of Education FMOH Federal Ministry of Health FOAG Federal Office of the Auditor General HSDP-III v
FP FY GAVI GC GDP GFATM GHP GMP GNP GOE HAART HAPCO HACCP HAP HCF HCFS HCUs HDI HEA HEC HEP HESP HEW HF HIPC HIS HIV HMIS HPN HPs HRD HSD&QC HSDP HSEP ICB IDA IEC/BCC IMCI IMF ITN JCCC JCM JHPTs JICA JRM JSI KAP KMC LTTA M&E MAPPP MOCB Family Planning Financial or Fiscal Year Global Alliance for Vaccines and Immunization Gregorian Calendar Gross Domestic Product Global Fund Against AIDS, Tuberculosis and Malaria Good Hygienic Practices Good Manufacturing Practices Gross National Product Government of Ethiopia Highly Active Anti Retroviral Treatment HIV/AIDS Prevention and Control Office Hazard Analysis and Critical Control Points Harmonization Action Plan Health Care Financing Health Care Financing Strategy Health Care Units Human Development Index Health Extension Agent Health Education Center Health Extension Package Health Extension Service Package Health Extension Workers Health Facility Highly Indebted Poor Countries Health Information System Human Immunodeficiency Virus Health Management Information System Health, Population and Nutrition Health Posts Human Resource Development Health Service Delivery and Quality of Care Health Sector Development Programme Health Service Extension Programme International Competitive Bidding International Development Association (World Bank) Information, Education and Communication/Behavioral Change Communication Integrated Management of Childhood Illnesses International Monetary Fund Insecticide Treated Nets Joint Core Coordinating Committee Joint Consultative Meeting (FMOH and HPN group) Junior Health Professional Trainings Japan International Cooperation Agency Joint Review Mission John Snow Incorporated Knowledge, Attitude and Practice Kangaroo Mother Care Long Term Technical Assistance Monitoring and Evaluation Medical Association of Physicians in Private Practice Ministry of Capacity Building HSDP-III vi
MDGs MDT MEDAC MEFF MHSP MMR MOCB MOF MOFED MPS MTR NAC NCB NDL NGOs NHA NIDS NNT NORAD OPV OR ORT PAP PASS PEP PER PHARMID PHCU PIM PLWHA PLWHA PMTCT PMTCT PPD PPPH PRSP RBM RED RH RHB RJSC RTCs SAFE SDPRP SNNPR SPM SPs STIs SSA TB TBAs TGE TLCP Millennium Development Goals Multi-Drug Therapy Ministry of Economic Development and Cooperation Macro-Economic Fiscal Framework Essential Health Services Package Maternal Mortality Rate Ministry of Capacity Building Ministry of Finance Ministry of Finance and Economic Development Making Pregnancy Safer Mid Term Review National Advisory Committee National Competitive Bidding National Drug List Non Governmental Organizations National Health Accounts National Immunization Days Neonatal Tetanus Norwegian Agency for International Development Oral Polio Vaccine Operational Research Oral Re-hydration Therapy Programme Action Plan Pharmaceutical Administration and Supply Service Public Expenditure Programme Public Expenditure Review Pharmaceuticals and Medical Supplies Import and Distribution Primary Health Care Unit Programme Implementation Manual People Living with HIV/AIDS People Living With HIV/AIDS Prevention of Mother to Child Transmission Prevention of Mother to Child Transmission Planning and Programming Department Public-Private Partnership for Health Poverty Reduction Strategy Paper Roll Back Malaria Reaching Every District Reproductive Health Regional Health Bureau Regional Joint Steering Committee Regional Training Centers Surgery, Antibiotic, Face washing and Environmental Improvement Sustainable Development and Poverty Reduction Program Southern Nations Nationalities and Peoples Region Strategic Planning & Management Special Pharmacies Sexually Transmitted Infections Sub Saharan Africa Tuberculosis Traditional Birth Attendants Transitional Government of Ethiopia Tuberculosis and Leprosy Control Programme HSDP-III vii
TOR TOTs UNAIDS UNDP UNFPA UNICEF VCT WHO ZHD Terms of Reference Training of Trainers Joint United Nations Programme on HIV/AIDS United Nations Development Programme United Nations Fund for Population Activities United Nations Children s Fund Voluntary Counseling and Testing World Health Organization Zonal Health Department HSDP-III viii
Preamble Ethiopia has been implementing Health Sector Development Programme (HSDP) since 1997/8 (1990 EFY). The first phase of HSDP was completed in 2002 (1994 EFY) and the second phase will be completed in June 2005 (1997 EFY). This necessitated the development of the third phase of HSDP, which covers a period of five year i.e. July 2005 to June 2010. Therefore, the Federal Ministry of Health (FMOH) established a National Planning Team (NPT), which is a multidisciplinary team of experts drawn from the different departments of FMOH in November 2005. The team was chaired by the Planning and Programming Department. The team modified the TOR already developed for the preparation of HSDP-III. This TOR was subsequently approved by the Management Committee of FMOH. The methodologies applied during the development of HSDP-III are: consultation of the existing Regional Health Bureaus (RHBs) and FMOH SPMs; development of the document in Strategic Planning Management (SPM) format; alignment of HSDSP with the Millennium Development Goals (MDGs), Health Service Extension Programme (HSEP), Accelerated Expansion of Primary Health Care Services, Child Survival Strategy, the Health Human Resource Development Plan and other relevant policy documents; consultation of existing health sector and health sector related documents such as HSDP II, ARM proceedings, JRM reports, Country Status Report on Poverty and Health, Health and Health Related Indicators etc; consultation of different experts in FMOH in specific areas. The Zero Draft of HSDSP was distributed to the Management Committee of FMOH and feedback was obtained on 2 nd February 2005. The document was amended based on the comment and distributed to the RHBs, the JCCC and the HPN Donor Group for their review and comment. Subsequently, first round consultation meetings were conducted between 23 rd and 31 st of March 2005 with the RHBs (three days), JCCC (half day) and HPN Donor Group (half day) at FMOH. The feedbacks obtained from these three stakeholders were carefully recorded and used to amend the document. In the mean time, the costing of HSDP-III was done by two technical experts from the World Bank and ESHE Project and included in the document. Subsequently, second round consultation was conducted with all stakeholders and the comments were incorporated to give the document the current shape. HSDP-III ix
1. Country Profile 1.1 Introduction This chapter gives an overview of the profile of Ethiopia in terms of geography and climate; population; education; administrative structure; socio-economic environment, health status and health system organization. 1.2 Geography and Climate Ethiopia, located in the North Eastern part of Africa, also known as the Horn of Africa, lies between 3 and 15 degrees north latitude and 33 and 48 degrees east longitude. With a total area of around 1.1 million square kilometers, it borders with five countries - Eritrea in the north, Djibouti in the east, Sudan in the west, Kenya in the south and Somalia in the southwest. The size of the country and its location has accorded it with diverse topography, geographic and climatic zones and resources. Its topographic features range from peaks as high as 4,550m above sea level at Ras Dashen to 110m below sea level in the Afar Depression 1 with most of the country, covering 40% of the land area, categorized as highland and lying above 1,500 meters above sea level. The Great East African Rift Valley divides the highland into two- the western and northern highlands and the southeastern. There are three broad ecological zones that follow the above topography. The Kolla or hot lowlands are found below approximately 1,000 meters, the Weyna Dega between 1000-1500 meters, and Dega or cool temperate highlands between 1500 and 3000 meters above sea level. Mean annual temperatures range from 10-16 0 c in the Dega, 16-29 0 c in the Weyna Dega and 23-33 0 c in the Kolla. In general, the highlands receive more rain than the lowlands with annual rainfalls of 500mm to over 2000mm for the former and 300mm to 700mm in the latter. In addition, irregularity of rainfall is a characteristic of climates in Ethiopia and the country is prone to recurrent droughts and famines. 1.3 Population Ethiopia s population has been growing rapidly in recent years. It has been growing at a rate of 2.7% p.a. since 2000, which means increment by 2 million persons annually. With a total Population of 71.07 million in 2004 2, it has become the second most populous country in Africa, following Nigeria, which has a population of 140 million. At an annual growth rate of 2.7%, the population is also expected to reach 82.1 Million by the year 2009 3. Nearly half of the population (49.7%) is female. The average household size is 4.8 4. 85% of the total population lives in rural areas, making Ethiopia one of the least urbanized countries in the world. As in many other developing countries the rate of growth of the urban population (4.1%) is higher than that of the total population (2.7%). Rapid population growth exacerbates critical gaps in basic health services especially when growth of the economy is low or per capita incomes are in decline. HSDP-III 1
The average population density is 57 per square km 5, with great variation among regions. Higher densities are found in the highland areas, mostly above the 1,500m contour line. About 23.2% of the population is concentrated on 9% of the land area putting pressure on cultivable land and contributing to environmental degradation. On the other hand, roughly 50 percent of the land area represents sparsely populated areas with nomadic or semi-nomadic pastoral people living in arid plains or in a semi-desert environment. The settlement pattern of the population and its density greatly affect the provision of health care including the accessibility and utilization of existing health care facilities. The structure of the population of Ethiopia shows the dominance of the young as is typical of many developing countries. About 43.5% of the population comprises those under the age of 15 years; 51.9% between the ages of 15 and 59 years and only 4.6 % aged 60 years and above. A large proportion of women (24%) are in the reproductive age (15-49 years). The main characteristic of the Ethiopian population is therefore its youthfulness, with children (0-14 years) and youth (15-24 years) together accounting for almost 64 percent of the total. Total fertility rate for the country is high with 5.9 children per woman during the years 1995 to 2000 6. The level of fertility is significantly lower in urban (TFR of 3.3) compared to rural (TFR of 6.4) areas of the country. Fertility is highest in the Oromia Region (6.4 births per woman) and lowest in Addis Ababa (1.9 births per woman). The overall dependency ratio for the country is estimated as 85.9 dependents per 100 people in the working age group 15-64. The impact of HIV/AIDS has also been exacerbating the dependency ratio by depleting the productive group of the population. 1.4 Education The general level of education has marked influence on the spread of diseases, the acceptability of health practices and utilization of modern health services. However, the literacy status of the population is low. The total adult literacy rate is 36% (46% for males and 25% for females). The gross enrollment ratio in primary schools at national level is 68.4% (59.1% for girls). 7 Although more than triple from the 20% enrollment level of 1994, it is still much lower than the Sub Saharan Africa (SSA) average of 86% 8. This makes the population more at risk of preventable diseases including HIV/AIDS. 1.5 Administrative structure The new Ethiopian constitution, introduced in 1994 created a federal government structure. The federal structure is composed of nine Regional States: Tigray, Afar, Amhara, Oromia, Somali, Benishangul Gumuz, Southern Nations Nationalities and Peoples Region (SNNPR), Gambella and Harrari and two city Administrations (Addis Ababa and Dire Dawa). The National Regional States and City Administrations are further divided into 611 woredas. Woreda is the basic decentralized administrative unit and has an administrative council composed of elected members. The 611 woredas are further divided into roughly 15,000 Kebeles organized under peasant associations in rural areas (10,000 Kebeles) and urban dwellers associations (5,000 Kebeles) in towns. HSDP-III 2
The Federal state has a bicameral parliament: the House of Peoples Representatives, whose members are elected from the regions, zones, woredas and kebeles; and the House of Federation, whose members are designated from their respective regions. The highest governing body of the national regional states is the Regional Council with elected members and headed by a president nominated by the party that holds the majority seats. The president is assisted by heads of various regional bureaus. Each region has its own parliament and is responsible for legislative and administrative functions except for foreign affairs and defense. With the devolution of power to regional governments, public service delivery, including health care, has to a large extent fallen under the jurisdiction of the regions. The approach has been to promote decentralization and meaningful participation of the population in local development activities. For administration of public health care, there is a Regional Health Bureau (RHB) at the Regional level. Due to the Government s commitment to further decentralize decisionmaking power, woredas are currently the basic units of planning and political administration. 1.6 The socio-economic environment Ethiopia is one of the least developed countries in the world with an estimated per capita income of US$100 or US$720 in purchasing power parity terms in 2002. 9 Poverty is pervasive with 47% of the population estimated to live below the poverty line. The UNDP s Human Development Index (HDI) for 2004 ranks Ethiopia 170 out of 177 countries and is estimated at 0.309 1. When adjusted for gender differences, the HDI in Ethiopia drops slightly to 0.297 reflecting some gender inequality. The Government has been implementing a comprehensive economic reform program over the past decade. This had an important bearing on developments in the health sector. Prior to 1991, economic policy was characterized by extensive Government controls, macro-economic imbalances and restriction on private sector initiative all of which resulted in low economic activity and persistent declines in economic growth. With a change of government in May 1991, new economic measures were put in place to operationalize a free market economy and redirect Government interventions to social and infrastructure development. In particular, health and education service delivery and investment in roads and water resources development were given prominence 2. The reform program has resulted in remarkable economic performance. Macro economic stability was attained and persistent declines in GDP reversed. In fact real GDP grew by an 1 The HDI measures, within one composite index, achievements (or lack thereof) in human development. It is calculated out of 1 and includes life expectancy at birth, adult literacy and school enrollment rates and adjusted per capita income in terms of purchasing power parity. To the extent that it is less than 1, the HDI reflects the shortfall in human development confirming that poverty is extensive. 2 Starting with the Transitional Period Economic Policy successive Recovery and Structural Adjustment Programs, underpinned by a series of Policy Framework Papers (PFPs) agreed with the World Bank and the International Monetary Fund (IMF), were put in place to stabilize and liberalize the economy and promote private sector participation. HSDP-III 3
average of 5.8% p.a. in the period covering 1992/93-2001/02. Seen against a population growth rate of 2.7% p.a. over the same period, this is a significant achievement. Year to year changes were however affected by external factors including the conflict with Eritrea and drought. Between 1998 and 2000 GDP growth was slowed by the conflict with Eritrea and in 2003 there was a sharp decline to a negative rate because of drought. There was a strong rebound since then with a real GDP growth rate of 11.6% in 2003/04 10. The economy recovered from the exceptionally poor performances of the previous two years due to good performance in agriculture. The policy environment created by the economic reform and macro economic stability and growth helped to address poverty in a comprehensive way through the adoption of the Sustainable Development and Poverty Reduction Program (SDPRP), which is now instrumental in prioritizing poverty related health program targets. The Government is also committed to meeting targets set by global initiatives notably, the Millennium Development Goals (MDG) and the recommendations of the WHO Commission on Macroeconomics and Health (CMH) aimed at strengthening the link between improved health and economic development. A marked feature of the reform is the strong commitment to shift the composition of government expenditures in favor of social and economic infrastructure. Accordingly, allocations to the health sector rose from around 3% to 6% from 1991 to 1997. During the first phase of the HSDP, the share of the health sector out of total Government budget allocations was maintained at around 5-6% despite the expansion in defense expenditures due to the war with Eritrea 11. Public expenditure on health as a percentage of GDP is 1.9%, with total health spending estimated at 5.6% of GDP 12. Recent increased government spending on health has been complemented by fiscal decentralization and broad reforms in the administration and management of public finance. Although spending on health both public and private has been increasing from US$ 4 to US$ 5.60 per capita, this is very low level compared to levels in SSA Countries i.e. Kenya (US$31), Uganda (US$18) and Tanzania (US $ 8) 13. Meeting the targets set by the CMH and for meeting the MDGs (about US$34 per capita) call for substantial increases of the present levels of spending on health. 1.7 Health status Ethiopia has poor health status relative to other low-income countries, even within SSA (see Table 1-1). This is largely attributed to preventable infectious ailments and nutritional deficiencies. Infectious and communicable diseases account for about 60-80 % of the health problems in the country. The Health and Health Related Indicator of MOH indicates that malaria, helminthiasis and respiratory tract infections are the major causes of outpatient visits at the health institutions. Widespread poverty along with general low income levels of the population, low education levels (especially among women), inadequate access to clean water and sanitation facilities and poor access to health services have contributed to the high burden of ill-health in the country. HSDP-III 4
Table 1-1 Comparison of Ethiopian Demographic data with that of the World and Sub- Saharan African Countries in year 2003 Population Mid-2003 (Millions) Births Per 1,000 Pop, Deaths per 1000 Pop. Rate of Natural Increase (%) Infant Mortality Rate Total Fertility Rate Percent of Population of Age Life Expectancy at Birth (Years) <15 65+ Total Male Female World 6,314 22 9 1.3 55 2.8 30 7 67 65 69 Ethiopia 71.1 39.9 13 2.7 96.8 5.9 44 3 54 53 55 Sub Saharan Africa 711 40 16 2.5 93 5.6 44 3 48 47 49 Average life expectancy at birth is also relatively low at 54 (53.4 for males and 55.4 for females) 14 and is further expected to decline to 49.4 years if present HIV infection rates continue 15. This situation is further aggravated by the high population growth. Young people constitute one third of the total population in Ethiopia. This implies a profound reproductive health needs. The major reproductive health problems faced by the young population in the country are gender inequality, early marriage, female genital cutting, unwanted pregnancy, closely spaced pregnancy, unsafe abortion, and Sexually Transmitted Infections (STIs) including HIV/AIDS 16. Poor nutritional status, infections and a high fertility rate, together with low levels of access to reproductive health and emergency obstetric services, contribute to one of the highest maternal mortality ratio in the world, which is 871/100,000 live births 17. Nutritional disorders rank among the top problems affecting the population in general and children and mothers in particular. EDHS 2000 found that: 52% of children under the age of five years were stunted while 26.3% were severely stunted; 11% were wasted and 1% severely wasted; 47% were underweight, and 16% severely underweight; Infant and under five mortality are97/1000 and 140/1000 respectively. Malaria remains as the major causes of morbidity as well as mortality in the country. A study conducted in year 2001 indicated that only 31% of cases of fever seen in health facilities were properly managed; only 7 % of children with malaria received early diagnosis and treatment and the case fatality rate was 5.2% 18. The HIV epidemic has taken off rapid over the last two decades and the prevalence is estimated at 4.4% of the adult population in 2003. It is also estimated that 1.5 million people are living with HIV/AIDS and this is a staggering number to cope with for a resource poor country. Although there is an encouraging result in the rate of progression of the epidemic in the last few years, the rate is not slow enough to be complacent. Given the size of the population and the magnitude of damage already inflicted, it will take a number of years to see a noticeable decline in the socio-economic impact of the disease. Likewise, despite the advances in management of HSDP-III 5
the epidemic and the increasing resource availability, the condition faced is still far from the ideal, one which is unlikely to give respite in the near future. Worldwide, non-communicable diseases account for some 60% of mortality and 47% morbidity 19. Changing nutritional intake is causing an increase in the incidence of diabetes and hypertension. Increasing urbanization contributes to an increase in morbidity and mortality from traffic accidents. It is estimated that by year 2020 over 70% of the global burden of diseases will be caused by non-communicable diseases. In Ethiopia, although a national data is no available, some small-scale studies show that chronic and non-communicable diseases are emerging as public health problems. For instance, study in Butajira area, Central Ethiopia showed that 24% of the DALYs is attributed to non-communicable disease 20. Another small-scale study in Jimma indicated a prevalence rate of 7.3% for cardio-vascular diseases, hypertension, asthma, epilepsy cancer and diabetes mellitus 21. Regarding mental health, studies have indicated that the prevalence of mental health problems range from 3.5% to 17% in Ethiopia with prevalence being higher among women 22. Drinking of alcohol, use of stimulant Chat and different internal strife aggravates these problems 23. In terms of DALYS, mental health problems accounted for 11% of the total loss 24. Ethiopia is also known to have one of the highest road traffic accident in the world. In one study, it was reported that the road traffic injury and fatality rates were 946 and 59.5 per 10,000 registered vehicles, respectively 25. 1.8 Health System Organization The Government of Ethiopia is committed to democracy and empowerment of the people. Decentralization has been used as an important instrument for the full realization of the rights and powers of the diversified population. The health policy has also emanated from commitment to democracy and gives strong emphasis to the fulfillment of the needs of the less privileged rural population. Arguably, the most significant policy influencing HSDP design and implementation is the policy on decentralization. This is well articulated within the constitution and in a number of major and supplementary proclamations, and provides the administrative context in which health sector activities take place. Important steps have been taken in the decentralization of the health care system. Decisionmaking processes in the development and implementation of the health system are shared between the Federal Ministry of Health (FMOH), the Regional Health Bureaus (RHBs) and the Woreda Health Offices. As a result of recent policy measures taken by the Government, the FMOH and the RHBs are made to function more on policy matters and technical support, while the woreda health offices have been made to play the pivotal roles of managing and coordinating the operation of the primary health care services at the woreda levels. A Primary Health Care Service should include preventive, promotive and basic curative services. In order to realize this, HSDP I introduced a four-tier system for health service delivery, characterized by a primary health care unit (PHCU), comprising one health center and five satellite health posts, and then the district hospital, zonal hospital and specialized hospital. A PHC-unit has been planned to serve 25,000 people, while a district and a zonal hospital are each HSDP-III 6
expected to serve 250,000 and 1,000,000 people respectively. The Health Sector has recently introduced an innovative health service delivery system through the implementation of the Health Service Extension Programme (HSEP). Accelerated Expansion of Primary Health Services strategy has also been endorsed as part of facilitating the implementation of the HSEP. Furthermore, there will be a restructuring of the health service delivery system in terms of the role of the health facilities and professional mix of the staff during the implementation of HSDP- III as indicated under the Policy Framework section of this document. Table 1:2 shows the number of health facilities and health facility to population ratio per region in 2003/04 (EFY 1996). These figures include government institutions, non-governmental organizations (NGOs) and the private sector, and the population figure is based on the CSA projections. However, it is important to note that the distribution of both the public and private health facilities is skewed towards the urban areas. The growing size and scope of the private health sector, both for profit and not-for-profit, offers an opportunity to enhance the health service coverage. An increasing number of indigenous and international NGOs are currently involved in various aspects of service delivery, and there are currently an estimated 1,299 private clinics and 18 private and NGO owned hospitals in the country. In addition, there are 275 pharmacies, 375 drug shops and 1,563 rural drug vendors in the country. Responsibility for logistical support is shared between FMOH and the RHB. Health Management Information System (HMIS) has been established for routine reporting of activities and health service utilization, and structures are in place for periodic monitoring and evaluation of the health system as a whole. Table 1-2 Regional Distributions of Health Facilities and their ratio to Population, 2003/04 Region Population (P) Hospital (H) H/P Health Center (HC) HC/P Health Post (HP) HP/P Private Clinic (PC) Tigray 4,113,000 12 342,750 32 128,531 164 25,079 30 137100 Afar 1,330,000 2 665,000 9 147,778 59 22,542 3 443333 Amhara 18,143,000 17 1,067,235 115 157,765 1128 16,084 175 103674 Oromia 25,098,000 29 865,448 167 150,287 440 57,041 492 51012 Somali 4,109,000 6 684,833 17 241,706 97 42,361 2 2054500 Ben.-Gumz 594,000 2 297,000 10 59,400 60 9,900 10 59400 SNNPR 14,085,000 16 880,313 127 110,906 801 17,584 154 91461 Gambella * 234,000 1 234,000 8 29,250 42 5,571 7 33429 Hareri 185,000 5 37,000 2 92,500 7 26,429 19 9737 Addis Ababa 2,805,000 30 93,500 27 103,889 78 35,962 387 7248 Dire Dawa 370,000 3 123,333 5 74,000 23 16,087 20 18500 National 71,066,000 123 564,016 519 136,929 2,899 24,514 1,299 54,708 Source: FMOH (2003/4) Health and Health-Related Indicators 1.9 Health Care Coverage and Utilization The overall potential health service coverage in EFY 1996 is estimated at 64.02% 3. However, this varies substantially among the regions depending on their topographic and demographic characteristics. Geographical distance from a health facility and socio economic factors are the 3 Potential Health Service Coverage is calculated by multiplying the total number of PHC facilities i.e HC, HS and HP by the respective standard number of population to be served i.e 25,000 for HC, 10,000 for HS and 5000 for HP, and dividing the sum of these numbers by the total population. PC/P HSDP-III 7
major obstacle for the bulk of the Ethiopian population. However, the trend over time shows that there is a steady increase both in coverage and utilization. The potential health service coverage has increased from 45% to 57% and then 64.02% during 1997, 2002 and 2004 respectively. The percapita health service utilization that was 27% until 2000 has increased to 36% in 2004 (see table 1-3). Table 1-3 Estimated Health Service Coverage and Utilization by Region, 2003/04 Region Population Potential service Outpatient visits per coverage (%) capita 26 Tigray Afar Amhara Oromia Somali B/Gum SNNPR Gambella Harari Addis Ababa Dire Dawa 4,113,000 1,330,000 18,143,000 25,098,000 4,109,000 594,000 14,085,000 234,000 185,000 2,805,000 370,000 83.39 72.93 46.93 60.98 43.56 198.65 75.61 226.50 148.65 86.45 100.00 0.77 0.75 0.37 0.38 0.09 0.69 0.15 0.10* 0.84 0.47 0.34 National 71,066,000.00 64.02 0.36 Coverage in terms of health workers remains poor. The existing number of health workers and health worker to population ratio for 2003/4 (EFY 1996) is shown in Table 1-4 below. Table 1-4 Health Workers /Population Ratio, 2003/4 Physician* Nurse Health Assistant Nurse & H. Assistant Environmental Health Worker Region Population No. Ratio No. Ratio No. Ratio No. Ratio No. Ratio Tigray 4,113,000 149 27,604 1,344 3,060 893 4,606 2,237 1,839 111 37,054 Afar 1,330,000 23 57,826 238 5,588 56 23,750 294 4,524 13 102,308 Amhara 18,143,000 267 67,951 1,580 11,483 1,032 17,580 2,612 6,946 267 67,951 Oromia 25,098,000 364 68,951 2,696 9,309 2,140 11,728 4,836 5,190 326 76,988 Somali 4,109,000 52 79,019 385 10,673 121 33,959 506 8,121 22 186,773 Benishangul 594,000 41 14,488 340 1,747 66 9,000 406 1,463 28 21,214 SNNPR 14,085,000 268 52,556 2,032 6,932 814 17,303 2,846 4,949 227 62,048 Gambella** 234,000 18 13,000 158 1,481 39 6,000 197 1,188 4 58,500 Hareri 185,000 54 3,426 214 864 61 3,033 275 673 8 23,125 Addis Ababa 2,805,000 221 12,692 811 3,459 335 8,373 1,146 2,448 6 467,500 Dire Dawa 370,000 33 11,212 145 2,552 31 11,935 176 2,102 11 33,636 Central 250 639 159 798 20 NGO 140 515 212 727 34 OGA 419 4,098 301 4,399 85 Private 380 349 368 717 7 National 71,066,000 2,679 26,527 15,544 4,572 6,628 10,722 22,172 3,205 1,169 60,792 WHO Standard 1:10,000 1:5,000 1:5,000 HSDP-III 8
As shown in the table, the physician to population ratio is much lower than the WHO minimum standard of one physician for 10,000 people. However, it is important to note that the figure is mainly based on health workers in the public sector due to lack of complete report from the private sector while substantial number of physicians working in the private sector are also providing service to the public. Besides, health assistants are known to work at all levels of the health system and their duties are more or less similar to that of the nurses. Despite the noticeable improvement in distribution of human resources as a result of actions taken in the last decade, there is still some concentration of health workers in regional capitals and places perceived to offer better facilities than others. 1.10 Health Care Financing Health services in Ethiopia are financed by four main sources. These are government (both federal and regional); bilateral and multilateral donors (both grants and loans); non-governmental organizations; and private contributions. The National Health Accounts exercise for financial year 2000/01 revealed that the major contribution is that of households' contribution (36%), government (33%), and bilateral and multilateral donors (16%) 27. HSDP-III 9
2. Overview of the Implementation of Health Sector Development Program-I and II The following topics highlight the plans, achievements and challenges encountered during the implementation of HSDP-I and II and the way foreword in relation to key programmatic areas. 2.1. Health Service Delivery and Quality of Care There are five subcomponents under this component. These are the Health Service Extension Programme (HSEP), Prevention and Control of Communicable Diseases, Family Health Services, Hygiene and Environmental Health Service and Medical Services. 2.1.1. The Health Service Extension Programme (HSEP) HSEP is a new initiative included in HSDP-II. It is an innovative community based health care delivery system aimed at creating healthy environment as well as healthful living. The main objective of HSEP is to improve access and equity to preventive essential health interventions provided at kebele and household levels with focus on sustained preventive health actions and increased health awareness. It also serves as effective mechanism for shifting health care resources from being dominantly urban to the rural areas where the majority of the country s population resides. Therefore HSEP could be considered as the most important institutional framework for achieving the MDGs. With regard to HSEP, 16 different packages have been rigorously produced. They have been made available in Amharic and English, printed and distributed to 24 technical and vocational training institutions, RHBs and the concerned bodies in the regional states. National student selection criteria and entry requirements are adopted in all regions and the working relationship between the FLHWs and HEWs is clarified. Regional implementation guidelines have also been developed and reporting formats have been adapted to regional realities. TOT was provided to 199 health workers and they subsequently trained 2,757 female HEWs. Pilot implementation was launched in 5 regions in 2002/03 and encouraging results were seen in terms of community s acceptance and demand for services provided through HSEP. Improvements were seen in construction and utilization of latrines, utilization rate of contraceptives and vaccination services in areas where the programme has been implemented so far. Furthermore, the HSEP has been modified to suit to the life style of the pastoralist population. In 2004/05, the total number of institutions selected and made available for training of HEWs has increased to 24 (from 14 in 2003/04). In the same year, the total number of students admitted for training is 7,138. It is important to monitor the programme closely in order to identify areas of challenge that should be tackled and key lessons that would contribute to improved outcome. Institutional arrangements for management of HSEP at all levels, putting regular supervision in place, monitoring the quality of training and soliciting cooperation of other social sectors are areas that need attention. Moreover, with the increased service demand that will be created through the HSDP-III 10
presence of two HEWs in each kebele, the need to ensure the sustained availability of infrastructure, vaccines and contraceptives becomes paramount. There is also a need to implement the same sort of HSEP in the urban areas; and in schools through collaboration with the concerned bodies at different levels. 2.1.2. Family Health Service With respect to maternal and child health services, the targets set during HSDP-I were to increase contraceptive prevalence rate from 9.8% to 15-20%; DPT3 coverage from 59.3 to 70-80%, and reduce population growth rate from 2.9% to 2.5-2.7%. The achievements at the end of HSDP-I with respect to these targets showed that contraceptive prevalence rate (CPR) increased to 17.2%, DPT3 coverage dropped to 51.5% and population growth rate as per the DHS 2000 was 2.7%. Although targets were not set for antenatal service (ANC) and postnatal service coverage at the beginning of HSDP-I, the progress with regard to these indicators showed that ANC coverage increased from 5% to 34% and postnatal service coverage increased from 3.5% to 7%. And during HSDP-II, the targets set were to increase the DPT3 coverage from 51.5% -70%; achieve polio elimination and certification by 2003; increase TT2 for pregnant women from 27% to 70% and for non-pregnant women from 14.8% to 32%; expand IMCI implementation to 80% of the health facilities; increase CPR from 18.7% to 24%, ANC coverage from 30% to 45% and proportion of deliveries assisted by trained health workers from 10% to 25%. The achievement by year 2003 (end of 1996 EFY i.e. a year before completion of HSDP-II) indicated that CPR increased to 23%, ANC coverage increased to 40.8%; proportion of deliveries assisted by trained health workers declined to 9.45%; and postnatal care attendance increased to 15.84% (from 3.5% in 1989). With regard to child health, DPT3 coverage has reached 61% and proportion of fully immunized children has reached 36.95% 28. Ethiopia has also been polio free for close to four years and AFP surveillance has achieved certification level standard except for the recently reported case of polio due to cross border infiltration of cases. Table 2-1 gives a summary of the targets and achievement during HSDP-I and II. Table 2-1-Summary of Targets and Achievements during HSDP-I and II in Maternal and Child Health Services Indicator HSDP-I HSDP-II Baseline Target Achievement Target Achievement DPT3 59.3 70-80%, 51.5 70 60.78 CPR 9.8% 15-20% 18.7 24%, 23 ANC 5% - 30 45 40.8 Ass delivery 3.5% - 7% 25 9.45 TT2 for pregnant - - 27 70% 31.9 TT2 for nonpregnant - - 14.8 32 17.1 Post natal care 3.5-6.8 20 15.84 coverage HSDP-III 11
In order to achieve these targets, perinatal and newborn health were identified as priority area in the Health Policy. Regarding maternal and adolescent health services, priority was given to the provision of Safe Motherhood services to cater for normal pregnancies, deliveries and referral centers for high-risk pregnancies; post abortion care; addressing the sexual and reproductive needs of adolescents; encouraging paternal involvement and discouraging harmful traditional practices; appropriate nutrition education to mothers and children and provision of family planning services. A number of operational researches have been conducted. The areas of the studies include contraceptive and logistic system, contraceptive training needs, Norplant implementation and community-based distribution, among others. A procedure manual for contraceptive logistic was also developed to implement an effective logistic system; trainings were provided to regional RH managers on contraceptive technologies and MPH courses and short courses to health workers were sponsored by UNFPA. A National Reproductive Health Taskforce with technical working group for Making Pregnancy Safer (MPS), family planning, nutrition, STIs/HIV, logistics and adolescent RH have been formed to assist the programme with resource mobilization, monitoring and development of appropriate policies and guidelines. An advocacy material that shows the maternal and newborn mortalities in Ethiopia and their impact in terms of economic loss and loss of lives was also developed using the REDUCE module. Making Pregnancy Safer was launched in 2001 and implemented in four regions on pilot basis. Health workers were also trained on basic emergency maternal and newborn lifesaving obstetric services, EOC, cesarean section and anesthesia. 10 hospitals and over 40 HCs were equipped with basic essential equipment and supplies, and vehicles were procured and distributed to enhance programme implementation and the referral system. The review of the programme conducted in year 2003 revealed improvement in the quality of service and handling of obstetric emergencies that stimulated the rapid scaling up of the programme coverage. With regard to child health, IMCI was adopted nationally in 1997 as a major strategy to reduce childhood mortality and morbidity and promote childhood development. It has three components i.e. improving: the skills of health workers, health systems, family and community practices. It links preventive and curative services and programmes such as immunization, nutrition, malaria and infectious diseases are implemented in an integrated manner. The main activities under IMCI are prevention and control of ARI, diarrhea, malaria, malnutrition, measles and HIV/AIDS. Since 2001, IMCI has been in its expansion phase, hence, 36% of health facilities are implementing IMCI and 4,303 health workers were trained (43% of the targeted 10,108). The district coverage is also about 23% (131 of the targeted 580 districts). Pr-service IMCI training is being provided to health workers of different categories in 65% of government health professional training institutions. Community IMCI activities are initiated in 9 regions while interventions are well underway in the two pilot regions (Amhara and Tigray). C-IMCI baseline surveys and needs assessment have been conducted. Moreover, essential materials for implementation of C-IMCI i.e. National Implementation Guideline and Communication Strategy, the 20 Key Family Practices for Ethiopia, training manual and Key Messages for Community HSDP-III 12
Resource Persons have been prepared and applied. The National Child Survival Strategy document, which addresses the major causes of child morbidity and mortality, was finalized and endorsed in 2004. Furthermore, Interagency Coordination Committee (ICC) has been established and meets regularly to address issues on improving routine EPI, supplementary immunization activities and disease surveillance. This committee also plays a key role in resource mobilization for EPI. Supplemental immunization of polio, measles and neonatal tetanus was introduced in order to reach the remote areas of the country, strengthen the routine immunization activity and eradicate/eliminate the 3 vaccine preventable diseases. Several sessions of training were given to midlevel managers and cold chain technicians using Midlevel Managers and Immunization in Practice Modules. The programme has also replaced the reusable syringe by AD syringe and all injection vaccines were given using the disposable syringes and safety boxes. Since the introduction of the Reaching Every District (RED) strategy, most woredas have been developing micro-plans. Major constraints encountered during the implementation of MCH programmes were: understaffing and high turnover of both technical and managerial staff at all levels, inadequate follow-up and supportive supervision, shortage of transportation, lack of motivation of service providers, and poorly functioning of outreach sites and weak referral system. There are also high vaccine wastage rates, critical shortage of basic equipment for the management of emergency obstetrics at facility level and short supply of contraceptives and vaccines. Regarding EPI, there is a high vaccine wastage rate (65% for BCG, 30% for measles, 20% for DPT, 15% for OPV and 10% for TT). This is mainly attributed to poor planning of static and outreach sessions, lack of awareness of the community, poor management of the cold chain system and the currently applied One Vial One Child Policy 29. One of the threats to EPI is the adjournment of GAVI s support for injection materials (2002-2004) necessitating the financing of these commodities from the Government Budget and other HSDP partners. The following are the future directions towards the improvement of MCH service. Operationalize the harmonization of maternal and child health programs with the Health Extension Programme. Accelerate capacity building at the Regional and District level for planning, training, follow up and support supervision. Building the capacity of training institutions to scale-up IMCI pre-service training through training of instructors and provision of financial and material support. Involve NGOs and the private sector to scale up maternal and child health interventions. Strengthen the collaboration and integration among relevant programs like RBM, EPI, Nutrition, MPS, IMCI and HIV/AIDS etc., to avoid duplication of efforts and maximize the impact. Optimally utilize the opportunity of the child survival initiative to scale up maternal and child health interventions. Introduce new vaccines against Hepatitis B and Haemophilus Influenzae. HSDP-III 13